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Welcome to the webcast
Welcome to the webcast
Using best practice to improve wound assessment
1. The health economic burden that wounds impose upon the NHS UK, health providers and the patient (Guest et al, 2015).
2. Wound care CQUIN Target 2017–19 — what does it mean?
3. Introduction of the new Best Practice Statement for improving holistic assessment of chronic wounds.
4. Best Practice IN practice.
Learning objectives
The findings suggest:
• The NHS treats 2.2million wounds — worryingly, over 30% of those wounds lacked a diagnosis
• Managing patients with wounds and their associated co-morbidities is estimated to cost the NHS £5.3 billion, which is higher than cost of managing obesity (£5 billionper annum)
• The average cost of unhealed wounds is more than twice that of healed wounds• Wound management is a nurse-led discipline, of which two-thirds is managed in the
community setting • 10.9 million community nurse visits recorded to manage wounds per annum • 18.9 million practice nurse clinic visits recorded to manage wounds per annum• Patients present with a high number of co-morbidities
The ‘Burden of Wounds’ study Guest et al, 2015
Lack of full holistic wound assessment
41% of all wounds were on the lower limb
• Doppler (ABPI) NOT performed on 85% of patients with an ‘unspecified ulcer’, but46% of those patients were in compression therapy
• 95% of patients with diabetic foot ulceration did not receive Doppler assessment
The ‘Burden of Wounds’ study(Guest et al, 2015)
Lack of full holistic wound assessment
Documentation of wound assessments indicated that:
• 12% of wounds had no location or diagnosis • 18% of wounds ‘on the leg’ with no further information
regarding wound type• 11% simply recorded as ‘open wound’• 41% of wounds summarised were not accurately diagnosed• 47% of venous leg ulcers (VLUs) were unhealed within
12 months • Cost of treatment of unhealed wounds for 12 months was
£13,500 (Guest et al, 2018a; 2018b)
The ‘Burden of Wounds’ study (Guest et al, 2015)
What is needed to improve the clinical outcomes of chronic wounds?
Full holistic assessment and documentation to include:
• Accurate and timely assessment of the patient (as a whole), the wound, skin and care environment to ensure an accurate diagnosis
o Patient co-morbidities are considered and optimised for healing potentialo Patients are involved in the planning of treatment, and clear, appropriate agreed goals are set with
them within a realistic timeframeo Utilises appropriate assessment tools and methods (e.g. Doppler)
Clinical care delivery implications of the ‘Burden of Wounds’ study
What is needed to improve the clinical outcomes of chronic wounds?
Full holistic assessment and documentation to include:
• Implement a structured care plan/dressing selection that incorporates continued and consistent reassessment/review. Involve senior team members when necessary
• Ensure all staff involved in wound care staff are appropriately trained and have completed relevant competency frameworks
• Listen and act to the patient experience/s
• Measure and report patient outcomes to ensure evidence-based and cost-effective care
Clinical care delivery implications of the ‘Burden of Wounds’ study
The CQUIN indicator for improving the assessment of wounds (CQUIN 10) is one of 13 indicators for 2017–2019 and is currently only applicable to community settings in England.
The goal of the indicator is: ‘To increase the number of full wound assessments for wounds which have failed to heal after four weeks’.
This CQUIN will enable service providers to:
• Review how their service is currently managed
• Implement relevant changes that will enable practitioners to undertake full wound assessments of all patients who have chronic wounds
• Ultimately improve clinical outcomes for the patient
Wound care CQUIN target
New Best Practice StatementImproving holistic assessment of chronic wounds
Best Practice StatementImproving holistic assessment of chronic wounds
Overall objective was to support healthcare professionals to improve the assessment of patients with chronic wounds by:
• Explaining the value and importance of holistic wound assessment
• Describing the principles underlying holistic wound assessment and summarising these as Best Practice Statements (BPSs) which support best practice management of patients with chronic wounds
• In addition to this, each BPS is accompanied by a patient expectation statement to emphasise the importance of patient involvement and explaining to them what they should expect from high quality wound assessment
• Holistic patient and wound assessment can empower the patient and support self-care
WHAT?
Improving holistic assessment of chronic wounds
• Holistic wound assessment considers the ‘whole’ patient and should comprise at least the components of the generic wound assessment minimum data set (MDS) (Coleman et al, 2017)
• By identifying factors that require intervention and indicating objectives for management, holistic wound assessment will guide appropriate patient and wound management
• Practitioners should be given sufficient time to perform holistic wound assessment
• Holistic wound assessment should be performed by a practitioner with sufficient knowledge and skills
WHEN?
Improving holistic assessment of chronic wounds
• Patients with a wound should receive holistic wound assessment on presentation • In acute settings, this should be within six hours of admission for one or more nights,
or on development of the wound
WHY?
Improving holistic assessment of chronic wounds
To ensure that the patient receives the most appropriate treatment in line with best practice that enables the primary objective of management, which usually is healing, to be met.
Ultimately, holistic wound assessment involves the collection and interpretation of data, which is used to diagnose the underlying cause of the wound and aid decision-making (Benbow, 2016).
Holistic assessment:
• Enables easy review of previous assessments• Systematically guides practitioners through holistic wound assessment and assists in promoting
continuity of care • Aids objective setting and care planning• Contributes to patient safety• Provides legal evidence of care undertaken• Serves as a resource for audit and research to evaluate care/outcomes or service delivery
(Andrews & St Aubyn, 2015)
HOW?
Improving holistic assessment of chronic wounds
The Expert Working Group recommends that holistic wound assessment includes at least the elements of the recently developed generic wound assessment MDS, including:
• General health information • Wound baseline information• Wound assessment parameters • Wound symptoms• Specialists referrals/investigations • Additional assessment parameters may be necessary according to wound type,
i.e. diabetic foot ulceration
Communicating to empower and engagePatient empowerment/engagement/involvement
Examples of open-ended questions to use during chronic wound assessment (adapted from Moore et al, 2016):
• What worries you about your wound?
• How does your wound affect daily living and your personal relationships?
• How do you feel about doing some of the care for your wound yourself?
• Who else can be involved to help you manage caring for your wound?
Factors that affect healing, quality of lifeand self-care
• Holistic wound assessment should identify any factors that may hinder healing or increase risk of further wound development
• Understanding how the wound is affecting the patient can enable the plan of care to include measures to reduce the wound’s impact on quality of life
• Patients should be empowered and encouraged to self-care where willing and able to do so safely
Assessing each wound
• The physical characteristics of, and symptoms associated with each wound should be assessed using the relevant parameters from the generic wound assessment MDS
• The location of each wound should be recorded accurately, using appropriate anatomical language and a body map
• Photography is recommended and should be used according to local policies and following appropriate patient consent
Correct anatomical terminology
Lateral
Distal
Medial
ProximalRight upper
quadrant
For full anatomical terminology, see BPS
Correct anatomical terminology
LateralMedial
Distal
Proximal
Assessing each woundConsistency of wound measurement technique is important for wound size monitoring.
Wound bed and periwound condition and volume/type of exudate will play a dominant role in selecting the wound dressing(s) and dressing change frequency.
Assessing each wound
Diagnosis of infection is usually based on clinical signs and symptoms; routine swabbing shouldbe avoided.
Assessment of other symptoms, such as pain, should be explored to determine severity, timing and triggers/relievers.
Assessing each wound1. Exudate volume and type.2. Wound bed appearance and tissue type, i.e. viable or non-viable.
Setting objectives and care planning
Specific — include the expected outcome, what needs to be done and who is responsible
Measurable — specify clear criteria for the outcome
Achievable — be realistic
Relevant — be appropriate
Timed — state when the objective should be achieved
Setting objectives and care planning
Patient has uncontrolled diabetes
• Improve control of diabetes mellitus• Educate the patient about the
importance of blood glucose control for improving healing
• Refer to a multidisciplinary team for further assessment of diabetes mellitus and medication review
Patient removes compression due to discomfort
• Reassess lower limb for signs and symptoms of deterioration of arterial status, including repeating ABPI
• Consider using a lower level of compression for 1–2 weeks, or using an alternative type of compression therapy, e.g. compression wraps
• Educate the patient about the need for compression therapy
• Review analgesia to reduce discomfort
Intermediate reviews at each dressing change
Improved?
Deteriorated?
Unchanged?
Improved?
If improving, check current regimen for suitability and adjust if necessary, i.e. discontinuing anti-microbial therapy.
Deteriorated?
Deterioration of patient/wound should trigger holistic wound reassessment and medical review of the patient.Wound objectives adjusted as appropriate.
Unchanged?
Continue current regimen until next dressing change or scheduled holistic reassessment.Patients at risk, or lack of change for two weeks or more, should prompt holistic reassessment.
Week 1 Week 2
Conducting holistic wound reassessment
Holistic wound reassessment should be carried out:
• By a registered practitioner who has the appropriate skillsand knowledge
• At least every two weeks and on discharge in acute settings
• At least every four weeks in primary care and community settings
Conducting holistic wound reassessment
Components of holistic reassessment:• Patients general health state of current comorbidities, changes in medication • All elements of generic wound assessment:
o Wound size percentage reduction in wound area after four weeks o Patient symptoms — pain, odour, leaking, swelling, inflammationo Determining reasons for non-healingo Updating objectives and plan of care and set date for next holistic
wound reassessment o Documenting healing outcomes and objectives for prevention of recurrence
Using telecommunication technology
The use of telecommunication technology to provide health care remotely has considerable potential as a means of containing costs, enhancing access to specialist services and improving patient quality of life (Gray et al, 2010; van Houwelingenet al, 2016).
Use should be in line with local policies and take into account issues such as patient confidentiality.
Improving assessment of wounds using CASE
CASE (BSN medical) aims to support you through the important steps that will improve assessment of wounds.
CASE takes an holistic approach for better wound healing outcomes via a new and simple acronym.
Best practice: a patient journey
Cause
Assess
Select
Evaluate
Best practice: a patient journey
Cause• Trauma/underlying venous disease
Assess
Select
Evaluate
Best practice: A patient journeyCause
Assess venous disease• Lipodermatosclerosis• Chronic two-year ulceration• Osteoarthritis• Crohn’s disease• 72 years old• Carer husband • High pain • High exudate volume• Malodourous • Patient feeling ‘low,’ tired and embarrassed by the wound• ABPI 8.4, perfusion good
= Holistic assessment SelectEvaluate
Best practice: a patient journeyCause
Assess
Select (TIME)• Debridement pad• Washing and cleansing • Emollient to intact skin• Antimicrobial dressing for two weeks• Superabsorbent secondary dressing• Compression therapy
= Agree objective and deliver care
Evaluate
Best practice: a patient journeyCause
Assess
Select
Evaluate• Wound improving• Antimicrobial dressing discontinued• Compression therapy changed to hosiery kit to
encourage self-care and improved quality of life• Consider long-term prevention, vascular option
= Evaluate and prevent
Summary• Improving assessment of wounds is high on the NHS agenda for the foreseeable future.
• The new Best Practice Statement ‘Improving holistic assessment of chronic wounds’ can assist practitioners in implementing evidence-based, effective wound assessment and management.
• Ensuring that all patients with chronic wounds receive holistic wound assessment has a positive effect on the physical, emotional and socioeconomic status of patients, healing rates, nursing time, and the financial costs of wound care.
• Use of a structured framework that incorporates holistic assessment (e.g. CASE from BSN medical), which includes establishing the cause of the wound, agreeing objectives and selecting and evaluating care, will assist practitioners in delivering care that is most appropriate for the patient and the wound.
Further free education
• Further free education and training is available via BSN medical’s educational academies
• Modules, including among others:• Anatomy and physiology of skin• Factors affecting wound healing• Infection management• Litigation and the law and the NHS• Improving the assessment of wounds
Welcome to the WebcastUsing best practice…
to treat wound infection: time to go green
Please join us for our next webcast
OCT
3 18:30
Time Joy Tickle Tissue Viability Specialist
Shropshire CommunityNHS Trust
Thank you forwatching!
Thank you forwatching!
